From early instability to recurrent burden: post-discharge heart failure events and subsequent mortality

Background

The early post-discharge period after hospitalization for acute heart failure (AHF) represents a phase of heightened clinical vulnerability. Although recurrent hospitalizations are recognized markers of poor prognosis, the temporal impact of early instability and the cumulative burden of post-discharge HF events on subsequent mortality remain incompletely characterized.

Objective

To evaluate the impact of early post-discharge instability and recurrent HF event burden on subsequent all-cause mortality using landmark analyses.

Methods

We conducted a retrospective observational cohort study including consecutive patients discharged alive after hospitalization for AHF (January 2019–October 2025). HF events were defined as HF rehospitalization or emergency department visits for HF. Two landmark analyses were performed:Early instability (0–30 days): patients alive at day 30 were classified according to ≥1 HF event within 30 days. Mortality was assessed after day 30.Recurrent burden (0–90 days): patients alive at day 90 were categorized as 0, 1, 2, or ≥3 HF events within 90 days. Mortality was assessed after day 90.

Time-to-event analyses were performed using Cox proportional hazards models adjusted for age, sex, admission systolic blood pressure, and heart rate.

Results

A total of 2,142 patients were discharged alive. Median follow-up for mortality was 350 days (IQR 60–866). Among patients alive at day 30, early instability (≥1 HF event within 30 days) was associated with higher subsequent mortality (adjusted HR 3.37, 95% CI 2.38–4.78; p<0.001).

At day 90, 1,510 patients remained alive and constituted the 90-day landmark cohort. Increasing HF event burden within 90 days was associated with stepwise increases in mortality after day 90:1 event: HR 1.61 (95% CI 1.04–2.50; p=0.032)2 events: HR 4.46 (95% CI 2.34–8.53; p<0.001)≥3 events: HR 6.30 (95% CI 1.98–20.09; p=0.002)

Conclusions

Early post-discharge instability and accumulating HF event burden identify a progressively higher-risk population beyond the index hospitalization. These findings support the concept of a dynamic post-discharge vulnerability phase, in which recurrent HF events mark transition to sustained high mortality risk.Early HF Instability and Mortality90-Day HF Burden and Survival